CALL-BACK
Call-back is, by far, the biggest problem that NHS 24 has.
Call-back has been used in the NHS for many years and was standard practice within some GP out-of-hours co-operatives. It was a perfectly acceptable means of short-term prioritisation when a number of calls came in over a short period. But that was managed use of call-back. Management within NHS 24 do their best to react to the additional pressures that arise (and fall heavily on the shoulders of nurse advisers) when the flow of call-back becomes a deluge. Call-back was never intended to be an integral part of day-to-day working in NHS 24. Indeed we shall see later that NHS 24 was specifically not designed for its use. Call-back was used within weeks of the first centre opening in 2002. It was then managed down but recurred in the following year and eventually rose to 21% of all calls registered by November 2003. Again it was managed down but returned in 2004 and remains a major problem to this day, particularly at weekends.
We have been critical of NHS 24, not so much for allowing its excessive use - because perhaps there seemed to be no alternative - but because there was a failure to recognise the major impact and consequences of prolonged intensive use of call-back. When call-back comes into play it has the effect of pulling everyone into a revolving door. Nurse advisers who would normally be dealing with "live" calls have to be switched to call-back duties. That means there are insufficient resources to advise live incoming calls and that in turn exacerbates the call-back queue. Call-back can have serious consequences for the local out-of-hours organisations - and secondary care - within Health Boards. On the basis of estimated volumes of "live" calls to NHS 24 Health Board primary care OOH services will staff up for the anticipated numbers of face-to-face consultations. Currently that generally means paying staff to stand in over those peak volume periods. But once call-back is heavily in play then calls which were originally made to NHS 24 within that peak period may well be responded to one, two hours later - or even much later in extreme circumstances. The staff engaged by the Health Board to cover the anticipated peak period have by then often gone off duty! Most of all, extensive use of call-back can seriously disadvantage the calling public: the frustration and often worry of sometimes waiting much longer than expected. In relatively urgent cases there is a further delay, first of all in getting a clinician to the caller and then perhaps getting the caller to an appropriate treatment centre (aspects which are of significant consequence for callers in remote and rural parts of Scotland).
We contended in our interim report, there could well be clinical risks in the use of call-back that had not been acknowledged by NHS 24 and thus not sufficiently assessed by NHS 24 management. Since then the Board of NHS 24 has carried out a very comprehensive risk assessment exercise across the whole range of call-back. We urge the Board of NHS 24 not to see that in any way as an alternative to tackling and resolving the underlying issues by implementing an action plan that addresses the root of this chronic problem.It now seems that NHS 24 may have failed to address the most problematic internal impact of prolonged and extensive use of call-back. NHS 24, in all of its 3 contact centres, was designed to receive and not to make calls. The whole concept was, as we know, that people would call the NHS 24 number and, where appropriate, would be put through to a nurse adviser who would respond accordingly. So all the technology and telephony has been geared to that end. Conversely the telephony available to make calls out repeatedly over a prolonged period is pretty basic. Yet many shifts most weeks of the year will currently be dealing with as many outgoing calls as incoming calls - and, through no fault of their own, the "unproductive" time spent by highly qualified nurse advisers going through all the practical, manual procedures of that is significant. Call-back by definition will increase workload and must be minimised.
It is very clear that when a call which needs the intervention of a nurse adviser is handled within a very short period the service provided is generally of a very high quality. If and when call-back can be minimised there is no reason to believe that NHS 24, on its own, cannot consistently provide that level of service except at times of extreme call volumes when it would require the help and support of health board primary care back-up.
But it remains a fundamental requirement for the NHS 24 service that calls coming through to it should be answered and then dealt with accordingly. We shall continually return to this fundamental requirement as we explore how the problems and challenges of NHS 24 might be effectively resolved.